Application for Disabled Person Permit

FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES Application FOR Disabled Person PARKING Permit HSMV 83039 Rev. 06/22/22 Please submit this form to your local tax collector office or license plate agency. This form is not valid for more than 12 months from the date of the certifying authority s signature. Please Print/Type below Application BY Disabled Person (See warning below.) I certify that I am a Person with one of the disabilities listed in section , Florida Statutes. I further state that my physician or other certifying practitioner has completed the statement of certification below on my behalf, as required in section , Florida Statutes. Name of Disabled Person as printed on their Florida Driver License or Identification Card Current Disabled Parking Permit Number (if applicable) Signature of Disabled Person or Guardian of the Disabled Person Date signed Date of Birth Sex Disabled Person s E-mail Address Disabled Person s Phone Number Address City State Zip Florida Driver License or Identification Number: (Required for permanent and temporary parking permits unless exception is noted by physician below) If applicable, check one of the following: I am a frequent traveler.

SPECIAL EXCEPTION: The severely disabled applicant named above applying for a permanent placard is unable to obtain a Florida driver license or Identification card. If the Special Exception box is checked, the certifying physician must provide his/her signature and date signed below.

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